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As shown recently by the untimely passing of the BBC journalist Bill Turnbull, too many people are diagnosed with prostate cancer too late. The evidence supports this: with 33 deaths from prostate cancer every day in the UK [1] not good enough for a disease which has multiple curative options when caught early enough. For men diagnosed late, in advanced stages, there is no curative option and only the prospect of medical therapy to palliate or at best gain temporary remission. With 5000 men each year (around 10% of new diagnoses) presenting as emergencies [2,3] the traditional model of patients suffering from symptoms before presenting to primary care clearly fails many. This is particularly true of diseases such as prostate cancer where symptoms may not be present until the disease is advanced, or metastatic [4].
We agree that there is no clear-cut consensus supporting mass screening for men using the PSA blood test. However there are multiple issues with prostate screening trials, including the recruitment of unselected populations, with over-representation of white men from higher socio-economic backgrounds and with disproportionately lower levels of ethnic minorities. Clearly this is an issue with a disease such as prostate cancer that affects black men twice as much as white men. Despite the conflicting evidence in screening, the latest data from 16-year follow-up in the European Randomised study of Screening for Prostate Cancer [5] shows a continuing reduction in the number needed to screen and treat to prevent one death from prostate cancer, with data now comparable or indeed less than breast cancer screening [6,7], for which there is a national programme in place.
What is clear is that we need to do better, and the debate should be about how we do better, not whether we should even try at all. Particularly with an initiative that is specifically aimed at helping the poorest members of society and ethnic minorities; that frequently have worse health outcomes.
Since the larger screening trials of the USA and Europe were initiated in the 1990’s there have been significant advances in prostate cancer diagnostics. MRI scanning has interjected itself between PSA, digital rectal examination and biopsies. This allows for fewer men to need biopsies (reducing morbidity) and increased accuracy of biopsies with MRI-based targeting. Biopsy technique has also advanced, with a new consensus developing for the use of transperineal prostate biopsies which offer significantly lower sepsis rates compared with trans-rectal biopsies [8] and the ability to do whole-gland targeting whilst still using local anaesthesia. Genetic research is also maturing with studies into the role of BRCA and polygenic risk scores showing the possibility of augmenting the diagnostic pathway further. The use of active surveillance for low-risk disease, now part of standard practice, further ameliorates the risk of unnecessary harm to patients.
Further study is of course needed however, the direction of travel is clear: we are getting better at early diagnosis in prostate cancer and have many pieces of the puzzle, but the picture remains incomplete. In the meantime the pandemic, economic issues and the looming energy crises continue to hit the poorest hardest of all. Offering them a new means to access healthcare should be viewed positively by all healthcare professionals, rather than deemed a means to “absolve their public health sins”. For all the criticism levelled at the initiative in your article, not one of the critics mentioned any alternative solution. Healthcare professionals simply attacking one another in this manner is unlikely to lead to progress for any of our patients. Alternative methods of accessing healthcare need to be explored, and initiatives to do this should be applauded.
References:
1. Cancer Research UK, https://www.cancerresearchuk.org/health-professional/cancer-statistics/s..., Accessed Sept 2022.
2. Herbert A, Abel GA, Winters S, McPhail S, Elliss-Brookes L, Lyratzopoulos G. Cancer diagnoses after emergency GP referral or A&E attendance in England: Determinants and time trends in routes to diagnosis data, 2006-2015. British Journal of General Practice 2019; 69: E724–30.
3. McPhail S, Elliss-Brookes L, Shelton J, et al. Emergency presentation of cancer and short-term mortality. British Journal of Cancer 2013; 109: 2027–34.
4. Gnanapragasam, V.J., Greenberg, D. & Burnet, N. Urinary symptoms and prostate cancer—the misconception that may be preventing earlier presentation and better survival outcomes. BMC Med 20, 264 (2022).
5. Hugosson J, Roobol MJ, Månsson M, Tammela TLJ, Zappa M, Nelen V, Kwiatkowski M, Lujan M, Carlsson SV, Talala KM, Lilja H, Denis LJ, Recker F, Paez A, Puliti D, Villers A, Rebillard X, Kilpeläinen TP, Stenman UH, Godtman RA, Stinesen Kollberg K, Moss SM, Kujala P, Taari K, Huber A, van der Kwast T, Heijnsdijk EA, Bangma C, De Koning HJ, Schröder FH, Auvinen A; ERSPC investigators. A 16-yr Follow-up of the European Randomized study of Screening for Prostate Cancer. Eur Urol. 2019 Jul;76(1):43-51.
6. Hendrick RE, Helvie MA. Mammography screening: a new estimate of number needed to screen to prevent one breast cancer death. AJR Am J Roentgenol. 2012 Mar;198(3):723-8.
7. The benefits and harms of breast cancer screening: an independent review. Lancet, 2012. 380: 1778.
8. Xiang J, Yan H, Li J, Wang X, Chen H, Zheng X. Transperineal versus transrectal prostate biopsy in the diagnosis of prostate cancer: a systematic review and meta-analysis. World J Surg Oncol. 2019 Feb 13;17(1):31.
Competing interests:
We hold research funding that is being used for research into early diagnosis for prostate cancer.
20 September 2022
Masood R Moghul
Urology Fellow
Dr Netty Kinsella, Mr Declan Cahill & Professor Nicholas James
The doctors mentioned here are right to be voicing concerns about NHS England's plan to "invite" men for discussion and PSA testing, regardless of whether they have symptoms or not.
It is screening in practice whatever spin the bureaucracy use to sell the idea to the public and the coalface of the NHS.
There is no evidence of higher death and morbidity rates directly attributed to prostate cancer due to the COVID-19 pandemic disruption, so this program is chasing prostate cancer caseload before the proof.
The pandemic offers a once-in-a-lifetime opportunity to look at the effect of modern public health programs on chronic diseases; no one would reasonably want such a disruption in healthcare services, but it will be even worse if we do not look at the consequences (or lack of) from not having "normal" standard of care.
We may very well overestimate the effect of big-ticket healthcare services many of us are complicit in peddling to the people.
Re: Prostate cancer: case finding scheme is unapproved “screening by stealth,” GPs claim
Dear Editors,
As shown recently by the untimely passing of the BBC journalist Bill Turnbull, too many people are diagnosed with prostate cancer too late. The evidence supports this: with 33 deaths from prostate cancer every day in the UK [1] not good enough for a disease which has multiple curative options when caught early enough. For men diagnosed late, in advanced stages, there is no curative option and only the prospect of medical therapy to palliate or at best gain temporary remission. With 5000 men each year (around 10% of new diagnoses) presenting as emergencies [2,3] the traditional model of patients suffering from symptoms before presenting to primary care clearly fails many. This is particularly true of diseases such as prostate cancer where symptoms may not be present until the disease is advanced, or metastatic [4].
We agree that there is no clear-cut consensus supporting mass screening for men using the PSA blood test. However there are multiple issues with prostate screening trials, including the recruitment of unselected populations, with over-representation of white men from higher socio-economic backgrounds and with disproportionately lower levels of ethnic minorities. Clearly this is an issue with a disease such as prostate cancer that affects black men twice as much as white men. Despite the conflicting evidence in screening, the latest data from 16-year follow-up in the European Randomised study of Screening for Prostate Cancer [5] shows a continuing reduction in the number needed to screen and treat to prevent one death from prostate cancer, with data now comparable or indeed less than breast cancer screening [6,7], for which there is a national programme in place.
What is clear is that we need to do better, and the debate should be about how we do better, not whether we should even try at all. Particularly with an initiative that is specifically aimed at helping the poorest members of society and ethnic minorities; that frequently have worse health outcomes.
Since the larger screening trials of the USA and Europe were initiated in the 1990’s there have been significant advances in prostate cancer diagnostics. MRI scanning has interjected itself between PSA, digital rectal examination and biopsies. This allows for fewer men to need biopsies (reducing morbidity) and increased accuracy of biopsies with MRI-based targeting. Biopsy technique has also advanced, with a new consensus developing for the use of transperineal prostate biopsies which offer significantly lower sepsis rates compared with trans-rectal biopsies [8] and the ability to do whole-gland targeting whilst still using local anaesthesia. Genetic research is also maturing with studies into the role of BRCA and polygenic risk scores showing the possibility of augmenting the diagnostic pathway further. The use of active surveillance for low-risk disease, now part of standard practice, further ameliorates the risk of unnecessary harm to patients.
Further study is of course needed however, the direction of travel is clear: we are getting better at early diagnosis in prostate cancer and have many pieces of the puzzle, but the picture remains incomplete. In the meantime the pandemic, economic issues and the looming energy crises continue to hit the poorest hardest of all. Offering them a new means to access healthcare should be viewed positively by all healthcare professionals, rather than deemed a means to “absolve their public health sins”. For all the criticism levelled at the initiative in your article, not one of the critics mentioned any alternative solution. Healthcare professionals simply attacking one another in this manner is unlikely to lead to progress for any of our patients. Alternative methods of accessing healthcare need to be explored, and initiatives to do this should be applauded.
References:
1. Cancer Research UK, https://www.cancerresearchuk.org/health-professional/cancer-statistics/s..., Accessed Sept 2022.
2. Herbert A, Abel GA, Winters S, McPhail S, Elliss-Brookes L, Lyratzopoulos G. Cancer diagnoses after emergency GP referral or A&E attendance in England: Determinants and time trends in routes to diagnosis data, 2006-2015. British Journal of General Practice 2019; 69: E724–30.
3. McPhail S, Elliss-Brookes L, Shelton J, et al. Emergency presentation of cancer and short-term mortality. British Journal of Cancer 2013; 109: 2027–34.
4. Gnanapragasam, V.J., Greenberg, D. & Burnet, N. Urinary symptoms and prostate cancer—the misconception that may be preventing earlier presentation and better survival outcomes. BMC Med 20, 264 (2022).
5. Hugosson J, Roobol MJ, Månsson M, Tammela TLJ, Zappa M, Nelen V, Kwiatkowski M, Lujan M, Carlsson SV, Talala KM, Lilja H, Denis LJ, Recker F, Paez A, Puliti D, Villers A, Rebillard X, Kilpeläinen TP, Stenman UH, Godtman RA, Stinesen Kollberg K, Moss SM, Kujala P, Taari K, Huber A, van der Kwast T, Heijnsdijk EA, Bangma C, De Koning HJ, Schröder FH, Auvinen A; ERSPC investigators. A 16-yr Follow-up of the European Randomized study of Screening for Prostate Cancer. Eur Urol. 2019 Jul;76(1):43-51.
6. Hendrick RE, Helvie MA. Mammography screening: a new estimate of number needed to screen to prevent one breast cancer death. AJR Am J Roentgenol. 2012 Mar;198(3):723-8.
7. The benefits and harms of breast cancer screening: an independent review. Lancet, 2012. 380: 1778.
8. Xiang J, Yan H, Li J, Wang X, Chen H, Zheng X. Transperineal versus transrectal prostate biopsy in the diagnosis of prostate cancer: a systematic review and meta-analysis. World J Surg Oncol. 2019 Feb 13;17(1):31.
Competing interests: We hold research funding that is being used for research into early diagnosis for prostate cancer.